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.n► <br /> WELAOM IIT APPLICATION P M SITE <br /> �#r'st�;`` r�► <br /> -Al fi MITIGATION <br /> SAN �►OUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 02 APR -8 Ph 1: 18 ENV#RONi�IEThirdALAM�DIVISION on, CA., 62OZ) <br /> 304 E. Weber, , <br /> (209)40-3"9 <br /> `ON RMNDA a PERMIT EXPIM 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to constrict and/or InstaA the worts described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1uWs <br /> `11`5.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> LAcatiolt� clot Cross Street City )M Dp��_Psmel#WELL <br /> PROPERTY Owne n� (L dress h m�1 ZipPhone# �/ <br /> C-67Contracb� � Address <br /> Consultant/Sub Contractor rasa City�py[ Lic# <br /> 618 Coordinates:X ,Y ,Township Range Section <br /> 1tKW TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER•) 0 0 OVER-BORE <br /> 0 SOIL BORING# <br /> XWELL# MW— klnvr� "3 0 PRESSURE GROUT <br /> —% Grout Specifications: <br /> COMMENTS: <br /> SPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,` toNITORING )WOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:­*UGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> (I OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,fist specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEINT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cerft that i have prepafod this application and that the work will be done in accordance with San Joaquin <br /> County s,Rules egulations,and all applicable California State Laws."ool ` <br /> Stned Title/Company <br /> Pft NameDate <br /> D P ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ <br /> WORK PLAN DATED: <br /> on q d By ilk Date Issued ���S�o-c_ Area LOQ/0� <br /> Appkedemut k"pecoon BY Data FMsd Inspection BY Date <br /> Dembudfon ku►pedlon BY Date <br /> cera/CONOnTONS. <br /> ACCOUNTING ONLY: AID# cervE <br /> PE CODEa FEE WFO AMOUNT RENTTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dos 9/27/00 <br />